Fig. 10.1
Portal triad occlusion (Pringle maneuver) and clamping of supraceliac aorta (quadruple vascular clamping)
10.3.3 Cavo-Caval Venous Bypass Procedures
The common principle of cavo-caval bypass procedures is the maintenance of a caval venous return by securing the cardiac preload. In precarious hemodynamic situations, preservation of the caval flow aims to decrease the risks of cardiac collapse. This is in contrast to programmed liver surgery when interruption of caval flow is usually well supported and can most often be compensated by appropriate intraoperative anesthesia-reanimation management with no need for venous bypass [7].
One of the first described procedures was the use of an endovenous shunt; the shunt is usually introduced through the right atrium and pushed down into the subhepatic vena cava (if it does not exit through the venous defect) (Fig. 10.2) [2, 8–11].
Fig. 10.2
Atrio-caval shunt
Successful use of endovenous shunts for the treatment of retrohepatic vena cava injuries is anecdotal in the literature. Outcomes of endovenous shunting seem less grim in the setting of open when compared to blunt traumatisms. Of note, some of the pioneers of the procedure in liver trauma have eventually abandoned endovenous shunts in favor of perihepatic packing (PHP) [1, 12–15].
The veno-venous bypass is another technique which was popularized by liver transplant surgeons. Veno-venous bypass has the theoretical advantage of remote cannulation sites at the level of the femoral vein and the internal jugular far from the injury site (Fig. 10.3) [16–20].
Fig. 10.3
Cavo-caval bypass
A sophisticated maneuver which is not always adapted to extremely urgent situations is the realization of a cardiopulmonary bypass. Theoretical advantages include proper blood oxygenation, adequate coronary perfusion, control of eventual cardiac arrest, and the ability of recirculation of blood loss collected by the operative field cannulas (Figs. 10.4 and 10.5) [21, 22]. Use of hypothermic cardioplegia has been suggested to allow increasing the duration of surgery and performing more complex reparations [23]. Reconstruction of the hepatico-caval junction after complete avulsion, as well as liver autotransplantation after back-table repair, has been reported [19]. Nevertheless, such data remain anecdotal and include success-related publication bias.
Fig. 10.4
Cardiopulmonary bypass: 1 atrial cannula, 2 aortic reinjection, 3 suction-reinjection cannulas in the thoracic and abdominal cavity
Fig. 10.5
High-velocity ski accident in a 14-year-old man. Transport of hemodynamically stable, hypothermic (33.3 °C) patient was made to trauma center; intubation on arrival motivated by extreme agitation. CT scan showed blood extravasation at the level of the suprahepatic IVC and the absence of associated injuries (a, b). Sternotomy, CBP, and laparotomy were successively done and confirmed complete disjunction of the vena cava and of the three suprahepatic veins (c). After complete liver vascular exclusion, the suprahepatic veins were anastomosed together and then on a 30 mm diameter Dacron graft (Hemashield®) (d), the graft was then sutured to the subdiaphragmatic IVC (e)
The dogma of systematic immediate repair of hepatico-caval injuries assisted or not by bypass procedures has been recently challenged [5]. Thorough analysis of successful reports suggests that most patients were actually hemodynamically stable prior to surgery. Hemodynamic stabilization was the result of either spontaneous bleeding contention by retroperitoneal structures or by surgical packing performed prior to patient transferal to level I trauma centers. Thus, it is likely that attempting to perform the complex aforementioned techniques during emergency surgery in hemodynamically collapsed patients has very small chances of success. It is probable that compression of the liver on itself and against the diaphragm supported by the establishment of perihepatic packing (PHP) offers the best chances of survival in such desperate situations.
10.3.4 Liver Resection to Obtain Access to the Retrohepatic Vena Cava
Theoretically, performing a right hepatectomy procedure allows exposure of the retrohepatic vena cava and direct access to the vascular defect. Some authors have proposed performing right liver resection for this indication, most often under cover of vascular exclusion of the liver [24]. Mortality of right hepatectomy performed on an emergency basis for bleeding control is prohibitive. Again, published successes correspond mostly to long management delays suggesting a contained bleeding pattern of the initial injury [25–27]. Exposure of right hepatectomy for retrohepatic caval injuries cannot be recommended in the presence of active bleeding [13].
10.3.5 Perihepatic Packing (PHP)
This technique has proven its effectiveness in the treatment of very severe blunt hepatic trauma. Complete liberation of the right liver is unnecessary, avoiding risks of massive intraoperative bleeding. Freeing adhesions located at the inferior part of the right lobe may be required occasionally, with no major risk. Compression of the right liver on the diaphragm is performed at the beginning by the surgeon’s hand and then progressively by pads leaning on the right kidney on the right side and on the stomach on the left side. Placing pads on the superior surface of the liver should be avoided as this might open the suprahepatic region (Fig. 10.6). PHP enables control of severe injuries of the retrohepatic IVC and of the hepatico-caval junction; performed as a step of damage control surgery, PHP may save the life of these patients in the emergency setting (Fig. 10.7). Over the last two decades, the literature on this topic is particularly compelling and justifies systematic use of PHP in the emergency setting. Emergency PHP should be performed without trying to understand the type of lesions, with the hope that bleeding control without definitive repair would allow resuscitation in the operating room at first, followed by transfer in the ICU and/or CT scan [13, 23, 28–31].
Fig. 10.6
Perihepatic packing of hepatico-caval junction injuries. Upward hand compression that “closed” the liver fracture has been replaced by subhepatic pads (a). Pad positioning above the liver should be prohibited as it may open liver injuries and aggravate bleeding (b)
Fig. 10.7
Ski accident in a 62-year-old hemodynamically stable woman. CT shows grade IV liver injuries and absence of vascular extravasation on the arterial and portal acquisition phases (a, b). There is important blood leakage from the middle suprahepatic vein on the late acquisition phase and intraperitoneal blood leakage (c, d). Hemodynamic deterioration during the procedure prompted immediate damage control laparotomy with “blind” PHP positioning. CT performed 2 days later shows bleeding cessation (e); subhepatic pads press the stomach and “wrinkle” the left liver lobe (f); on the right side it is almost exclusively under the liver and pushing on the kidney (g, h)
10.3.6 Nonoperative Management
CT performed in hemodynamically stable trauma patients may show injuries of the retrohepatic vena cava or of the hepatico-caval junction which are contained to the retroperitoneum or do no longer bleed. In circumstances when secondary alteration of the hemodynamical condition requires surgical exploration (Fig. 10.7), information provided by CT is particularly useful for subsequent intraoperative decision-making. The monitoring of nonoperated patients can lead to discovery of partial or total thrombosis of hepatic veins: usually this does not justify complex desobstruction procedures but warrant secondary anticoagulation treatment [32].
10.3.7 Liver Transplantation
Liver transplantation is situated at the upper end of aggressive therapeutic means available for the management of hepatico-caval vein injuries. In rare cases acute liver failure has been reported after a more or less effective and more or less stricturing control of suprahepatic vein bleeding. In most reported LT cases, venous injuries were part of severe liver trauma. The majority of published cases include patients who developed liver insufficiency after failure of a previously attempted lifesaving strategy [33].
10.4 Management Strategies
10.4.1 Hemodynamically Unstable Patient: Emergency Laparotomy Mandatory
As soon as it becomes obvious that the bleeding originates from the supra-/retrohepatic area, the surgeon should realize a compression of the liver against the diaphragm. In case of hemodynamic collapse, the surgeon may be constrained to transiently associate an aortic compression against the vertebral block to allow resuscitation and recover an acceptable arterial pressure. Attempts should not be made to “look and see” the supra-/retrohepatic injuries which implies hazardous hepatic mobilization, source of uncontrollable bleeding. After rapid exploration of the abdomen, manual compression is progressively replaced by pads firmly pressed against the right kidney and the stomach. In most cases this maneuver is sufficient to stop the bleeding. At this point consultation with the anesthesiologist allows identification of the lethal triad (hypothermia, acidosis, coagulopathy) which should prompt adopting an abbreviated laparotomy strategy. In favorable situations the patient can stand exclusive skin closure and transfer to the intensive care unit (ICU) improving conditions to control the lethal triad; if the patient condition allows, angiography-CT scan (with late-passage sequences) should be performed at this point to evaluate the extent of anatomical venous damage. This is the type of situation described in the literature in which patients can be transferred in level I trauma centers and benefit of specific expertise (vascular exclusion repair, venous bypass techniques, liver resection, transplantation); in some cases PHP suffices and further injury repair may prove unnecessary [27, 29].
If PHP does not contain the bleeding, the surgeon must try to improve its effectiveness by increasing the compression of the liver alongside with intensification by the anesthesiologist of resuscitation means on table. In specific situation when hepatic pedicle clamping clearly improves the hemodynamic condition (evoking associated injuries of the hepatic artery and/or its branches), the extremity of the turnstile can be exteriorized through the skin closure to allow attempting extreme emergency arterial embolization; if interventional radiology is unavailable, clamping or definitive ligation of the hepatic artery can be attempted.
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